What is the typical dose of propranolol (beta-blocker) for anxiety-related tachycardia?

Propranolol Dosing for Anxiety-Related Tachycardia

For anxiety-related tachycardia, start propranolol immediate-release at 10-40 mg three to four times daily (total 30-160 mg/day), titrating based on symptom control and heart rate response. 1

Initial Dosing Strategy

• Begin with propranolol immediate-release 10-40 mg three to four times daily, as recommended by the American College of Cardiology for symptomatic tachyarrhythmias 1
• For patients preferring once-daily dosing, the long-acting formulation can be started at 80 mg once daily, with titration to 120-160 mg daily for maintenance 1
• Improvement in somatic symptoms (tremor, palpitations) occurs within 1-2 hours at relatively low doses (40 mg/day) 2

Dose Titration and Optimization

• Most patients with anxiety achieve adequate symptom control with 80-320 mg daily of immediate-release propranolol 3
• The target is to achieve virtual abolition of orthostatic and hyperventilatory tachycardia, indicating adequate beta-blockade 3
• Approximately 50% of patients achieve clinically significant reduction in exercise tachycardia (≥20 bpm decrease) with 160 mg per day 4
• Only one-third of patients respond adequately at doses ≤160 mg/day, while an additional 40% require 200-640 mg/day for optimal effect 5
• Plasma propranolol levels above 20 ng/ml are needed to induce significant beta-blockade, typically achieved with daily doses slightly exceeding 160 mg 4

Mandatory Pre-Treatment Screening

Before initiating propranolol, you must screen for absolute contraindications:

• Cardiogenic shock or hypotension 1
• Active asthma or obstructive airway disease 1
• Perform baseline cardiovascular examination with auscultation 1

Monitoring During Treatment

• Watch for hypotension and bradycardia, especially during dose escalation 1
• In diabetic patients, counsel that propranolol may mask hypoglycemia symptoms (tremor, tachycardia) 1
• Assess symptom response at each visit and adjust dosing accordingly 1

Critical Safety Warnings

• Never abruptly discontinue propranolol after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or angina 1
• Avoid combining with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to severe bradycardia and heart block risk 1
• Some patients exhibit a biphasic dose-response curve, where arrhythmia frequency decreases at lower doses but paradoxically increases at higher doses above the optimal level 5

Long-Term Considerations

• With sustained treatment at higher doses (160 mg/day), improvement in psychic anxiety symptoms may emerge after several weeks, beyond the immediate somatic symptom relief 2
• Propranolol requirements often diminish over time, and lasting remissions are not infrequent 3
• Depression, present in approximately 50% of anxiety patients, usually improves with propranolol but may persist in one-third as a lone symptom requiring antidepressant therapy 3

Alternative Formulation for Acute Situations

• For acute anxiety episodes requiring rapid control, IV propranolol can be given as 1 mg over 1 minute, repeated every 2 minutes up to 3 doses maximum 1